I authorize Dr. Varinderjit Kaur Thind D.D.S. (Health Care Provider) to keep my signature on file and charge my credit account for the balance of charges not paid by insurance within forty five (45) days after receiving the first payment from insurance company.
I assign my insurance benefits to Dr. Thind. I understand this form is valid unless I cancel the authorization through written notice to the health care provider.
I understand and agree to pay full amount for the treatment at the time of check-out.(If you have a dental insurance, we will submit a claim to your insurance company, the benefit will be assigned to you.)
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